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Facilic Supervision and Schematics:The Art of Training PsychiatricResidents and Other Mental HealthProfessionals How to StructureClinical Interviews Sensitively

Shawn Christopher Shea, MDa , b,*, Christine Barney, MD b

a

Training Institute for Suicide Assessment and Clinical Interviewing, 1502 Route 123 North,Stoddard, NH 03464, USA bDartmouth Medical School, Hanover, NH, USA

Every day, live theater unfolds as two strangers step into the roles of clini-cian and patient to engage in a brief but complex interaction—the initialinterview. This unscripted play may have remarkably important ramifi-

cations. As the players collaboratively create the script, the clinician is respon-sible for gathering a daunting amount of material that may be of use in

relieving the pain of the patient.The interviewer must uncover the patient’s presenting problems, perspec-

tives, symptoms, and diagnostic complexities. In addition, the interviewermust be able to explore information regarding an array of social supportsand circumstances that may be hindering the patient or may prove to be of po-tential use in helping the patient. Unlike an actor, however, the clinician’s task isnot to create a role but sensitively to help the patient drop the many social rolesthat can prevent the patient from sharing the intimate details of his or her story.To magnify the task further, all of this material must be gathered in roughly

50 minutes while establishing and maintaining a powerful therapeutic alliance.Put succinctly, good clinicians cannot afford merely to listen empathically:

they also must learn to explore actively in a comprehensive yet sensitive fash-ion. Indeed, gifted clinicians have the knack for exploring this vast database insuch a fashion that patients come away feeling that they have been participating in an engaging conversation with a caring human being rather than having

been interviewed by ‘‘some shrink with a clipboard.’’This critical ability to gather a useful database while simultaneously enhanc-

ing engagement is one of the most difficult clinical skills to master, but painfully

*Corresponding author. Training Institute for Suicide Assessment and Clinical Interviewing,1502 Route 123 North, Stoddard, NH 03464. (Website: www.suicideassessment.com).E-mail addresses: [email protected] (S.C. Shea).

0193-953X/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.psc.2007.03.003 psych.theclinics.com

Psychiatr Clin N Am 30 (2007) e51–e96

PSYCHIATRIC CLINICSOF NORTH AMERICA

http://www.suicideassessment.com/

mailto:[email protected]

mailto:[email protected]




little time is spent in many a clinician’s training regarding its mastery. In themid-1980s, when I was developing the interviewing course at Western Psychi-atric Institute and Clinic at the University of Pittsburgh [1,2] (also described indetail elsewhere in this issue), I quickly realized that one of the problems facing interviewing mentors was that no supervision language existed with which onecould easily discuss, model, and teach these elusive structuring skills.

Supervision languages existed for talking about a variety of interviewing skills, such as recognizing defense mechanisms and the use of specific typesof clinician responses (eg, open-ended questions and empathic statements).Moreover, broad fields of study had been delineated regarding important non-verbal considerations such as proxemics [3] (the study of how people use space)and kinesics [4] (the study of how people use gestures and body motion), butno language had been developed to understand and describe how interviewersstructure and shape interviews as they gather data.

At Western Psychiatric Institute and Clinic we developed a new field of study and a supervision language with which to explore this field [5]. ‘‘Facilics’’is the study of how interviewers structure interviews while gathering data (eg,what topics they choose to explore, how they go about exploring those topics,how they make transitions from topic to topic) and the manner in which theyapproach this task while managing time constraints. The term ‘‘facilics’’ is de-rived from the Latin root facilis , indicating grace in movement.

In addition to the baseline definitions and principles created for this study of how clinicians go about the task of structuring interviews, a schematic short-hand was developed that allows a supervisor to note the flow of the student’sinterview quickly and unobtrusively. After the client has left the room, thesupervisor can share this ‘‘map’’ with the student, visually, in a fashion thatis easily understood and can shed light immediately on the student’s strengthsand weaknesses.

Facilic supervision proved to be the single most popular teaching tool that weused with residents in their interviewing training [1]. Facilics also can be used to

study the structuring of any type of interview, from clinical interviews to news-paper interviews to an attorney’s deposition to a late-night television host chat-ting with a celebrity. Facilics is not a way to interview; it is a way to capture andstudy how ably someone structures an interview.

Absolutely all interviews have a structure. Sometimes this structure is fluid.Sometimes it is awkward. Sometimes the interviewer is consciously aware of creating the structure. Sometimes the interviewer does not have the foggiestidea that a structure is being created. Nevertheless, a structure inevitably un-folds as any two people—in this case a clinician and a patient—try to navigate

the other’s defenses while communicating about intimate topics that are filledwith nuance and shadows.

As supervisors we can use an understanding of facilics to give our studentsa refreshing, and sometimes surprising, self-awareness of how each of thempossesses a characteristic style of structuring interviews. Through our use of facilic principles and schematics we can show students the myriad of creative

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options that they can use to facilitate communication with their patients and toweave clinical interviews that move with the easy flow of an everydayconversation.

Facilics provides one more valuable framework, among the many alreadyuseful supervision languages, for our students’ use as they diligently work atdeveloping an ever-more-active observing ego. An understanding of facilicprinciples enhances the resident’s approach to self-observation by providing an additional lens for understanding the mysteries of the interviewing process.This powerful new lens shows trainees methods for sculpting interviews so thatimportant databases are gathered in an engaging fashion, minimal informationof use in helping the client is missed, sensitive material is shared more readily,and the client is more likely to show up for a second appointment and/or tofollow up with the recommendations of the clinician.

Facilic supervision is composed of two activities: (1) the ‘‘tagging’’ of the stu-dent’s style of structuring for purposes of self-awareness, and (2) the clinicalapplication of facilic principles and language to give the student practical sug-gestions on how to structure interviews more effectively.

Parts of this monograph were adapted from the chapter, ‘‘The Dynamic Struc-ture of the Interview,’’ in the second edition of Psychiatric Interviewing: The Art of Un- derstanding [6], which provides a thorough introduction to the use of facilics fortrainees. The chapter introduces trainees to the facilic tagging system and pro-

vides practical suggestions on how to structure interviews in a conversationalfashion that optimizes interviewers’ data gathering and their ability to enhanceengagement.

Even more comprehensively than the chapter in the book, this monographfocuses on the first activity of facilic supervision: how to use the language totag the student’s style of structuring. The goal is to give the reader a solid un-derstanding of the language of facilics, securing a more effective use of the lan-guage for use during supervision. We hope the monograph will enable thereader to ‘‘hit the road running’’ with an approach that is faithful to the model

and simultaneously will help the mentor communicate the model quickly andclearly to students. The monograph also looks at some topics not covered inthe book chapter, topics that focus specifically on creative methods for optimiz-ing the use of facilics as a supervision tool and for communicating one’s ownopinions on how to structure interviews in a powerful and persuasive fashion.In short, you are holding a teacher’s manual.

In addition to my use of facilic supervision at the Western Psychiatric Instituteand Clinic, the Dartmouth Interviewing Mentorship Program, described else-where in this issue, has provided a lively clinical laboratory in which my co-au-

thor and I have had the privilege of using this tool for the past 17 years. We hopethat, with our combined experience of nearly 40 years in using facilic supervi-sion, we can provide the interested supervisor with a matter-of-fact introductioncomprehensive enough to be applied immediately to clinical training.

The facilic supervision system described in this article has well-establishedface validity and has been used extensively. During the past 25 years, facilic

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techniques have been translated into a variety of languages including Chinese,French, and Spanish. Facilics has been used in graduate programs both nation-ally and internationally across numerous disciplines including psychiatry, nurs-ing, counseling, clinical psychology, and social work. Its principles have beenpresented at the annual meetings of the American Association of Directors of Psychiatric Residency Training and the American Psychiatric Associationand in a variety of major clinical symposia including the Cape Cod Symposia,the Santa Fe Symposia, the Door County Institute, and the Muskoka SummerSeminar Series sponsored by McMaster University.

Despite the widespread use of facilics, a practical manual has never beenavailable to guide supervisors new to the system and its application. Thismonograph was created to fill this gap in the clinical education literature.

Our approach in the monograph is fourfold: (1) to introduce the basic facilicdefinitions and terminology, (2) to describe the facilic schematic system, (3) toshare tips and strategies for using facilic supervision more effectively, and (4) toprovide a programmed text in the Appendix that will expand and consolidatethe reader’s knowledge of both the principles of facilic supervision and the useof the facilic shorthand. By the end of this article and its Appendix, we hopethat the reader will have enough familiarity with the facilic system to be ableto use it immediately as a supervision tool.

DEFINITIONS OF FACILIC SUPERVISION TERMINOLOGY Facilics focuses on the following series of concepts: the topics being explored dur-ing an interview (called ‘‘regions’’), the method of exploring these topics oncethey are entered (a process referred to as an ‘‘expansion’’), and the methods of making transitions between topics (an interviewing structure called a ‘‘gate’’). Re-gions are divided further into two types, content regions and process regions.

Content RegionsA content region is any area of an interview in which the primary focus of the

interviewer is on the delineation of a specific database (naturally, the inter-viewer is attending simultaneously to rapport). For a clinical interview thefollowing 10 regions are often focused on in no specific order:

History of the present illnessDiagnostic regions (areas in which symptoms are elicited relating to specific

DSM-IV-TR diagnoses)The patient’s perspectives and goals (understanding the patient’s views on his or

her problems, the patient’s ideas about what might help, and his or her fears,pains, and expectations)

Mental status examination (Many elements of the mental status are evaluated si-multaneously with the exploration of the other regions. The more specializedcognitive mental status, in which a clinician examines orientation, attentionspan, memory functions, and general intellect, tends to form a more discreteregion that is easily identifiable during an interview.)

Social historyFamily history

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Elicitation of suicidal/homicidal history, ideation, and intentPast psychiatric history and treatmentDevelopmental and psychogenetic history

Medical history and review of systems

This brief survey shows that despite the immensity of the database culled inan initial interview, the contents tend to fall into relatively discrete regions.Some of these regions tend to overlap. In general, however, a given sectionof an interview tends to focus on a single region, much as an everyday conver-sation tends to focus on a single topic at a time. In the following excerpt thecontent region concerning drug and alcohol abuse is readily apparent.

Clinician: So right now you haven’t been using alcohol?

Patient: No.Clinician: You talked about using drugs in the past. I’m wondering what kind of

things you used then and now.Patient: Right now I’m only using pot. I don’t mess around with anything else.Clinician: Are you using it everyday?Patient: Almost every day.Clinician: How many joints might you have in a day?Patient: Maybe split two; me and Jack might split two.Clinician: Uh, huh.Patient: Because it really does calm me down. It doesn’t make you sick like al-

cohol can make you sick, or give you a bad head the next day. It just relaxesyou.

Clinician: Any type of pills you’re taking now?Patient: No.Clinician: Nothing but the marijuana . . . What kinds of drugs were you using in

the past?Patient: Well, I never got into any one drug real heavy.Clinician: Uh, huh.Patient: But I have taken LSD, speed, different goofballs, and stuff . . . but I never

injected any drugs like dope.

Expansion of Content RegionsDifferent trainees may display a broad range of skill in how skillfully andgracefully they can expand a specific content region such as the elicitation of the diagnostic criteria of a major depression or the exploration of a socialhistory.

Speaking broadly, two styles of gathering any given database can be ob-served, and these styles represent opposing extremes: ‘‘stilted expansions’’

and ‘‘blended expansions.’’ (In actuality these styles represent a continuumof skill.) In stilted expansions, the expansion lacks a feeling of conversationalflow. Instead, the client is asked a series of questions that seem somewhatforced because the interviewer is rigidly attempting to get specific answers.This type of expansion may cause a client to experience the unpleasant feeling mentioned earlier that he or she is ‘‘being interviewed’’ rather than talking with




someone. To describe stilted expansions more vividly, we sometimes call thema ‘‘Meet the Press’’ type of interview. Rigidly structured interviews sometimesfoster this style of expansion, as illustrated here:

Patient: The pressures at home have really reached a crisis point. I’m not certainwhere it will all lead; I only know I’m feeling the heat.

Clinician: What’s your appetite like?Patient: I guess it’s okay. . ..Clinician: What’s your sleep like?Patient: Not too good. I have a hard time falling asleep. My days are such

a blur. I never feel balanced, even when I try to fall asleep. I can’t concen-trate enough to even read.

Clinician: What about your sexual drive?

Patient: What do you mean?Clinician: Have you noticed any changes in how interested you are in sex?Patient: Maybe a little.Clinician: In what direction?Patient: I guess I’m not as interested in sex as I used to be.Clinician: And what about your energy level? How has it been?Patient: Fairly uneven. It’s hard to explain; but sometimes I don’t feel like doing

anything.

This particular trainee seems doggedly intent on rigidly expanding the

depression region, specifically the neurovegetative symptoms of depression.This style of expansion exhibits a mechanical quality, as if the interviewerhas a list of questions to reel off. Such rigidity characterizes stilted expansions.

As a contrast, in a blended expansion the interviewer once again focuses ona specific region of data. In this expansion, however, the interviewer attemptsto blend the questions into the natural flow of the conversation. Instead of thefeeling that they are ‘‘being interviewed,’’ this type of expansion creates in cli-ents a sense of gentle flow that tends to foster the engagement process. More-over, by decreasing the anxiety of the patient, this type of more naturalistic

interviewing may enhance both the quality and validity of the database.In the following excerpt, a blended expansion unfolds, once again exploring the depression region:

Patient: The pressures at home have really reached a crisis point. I’m not certainwhere it will all lead; I only know I’m feeling the heat.

Clinician: Sounds like you’ve been going through a lot. How has it affected theway you feel in general?

Patient: I always feel drained. I’m simply tired. Life seems like one giant chore.Clinician: What about your sleep? Has that been affected as well?

Patient: Absolutely. Perhaps that’s the reason I’m drained. I just can’t rest. Mysleep is horrible.Clinician: Tell me more about it, what it actually feels like.Patient: I can’t fall asleep. It takes several hours just to get to sleep. I’m wired. I’m

wired even in the day. And I’m so agitated I can’t concentrate, even enoughto read to put me to sleep.

Clinician: Once you’re asleep, do you stay asleep?

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Patient: Never, I bet I wake up four or five times a night. And about 5:00 AM I’mawake, as if someone slapped me.

Clinician: How do you mean?

Patient: It’s like an alarm went off, and no matter how hard I try, I can’t get backto sleep.

Clinician: What do you do instead?Patient: Worry . . . I’m not kidding . . .. My mind fills with all sorts of worthless

junk.Clinician: That sounds really unpleasant.Patient: Yea, it is.Clinician: We might be able to help you with that.Patient: That would be super.Clinician: You mentioned earlier that you were also having problems with con-

centration. Tell me a little more about that.Patient: Just simply can’t function like I used to. Dictating letters, reading, writing

notes, all those things take much longer than usual. It really disturbs me. Mysystem seems out of whack.

Clinician: Do you think your appetite has been affected as well?Patient: No question. My appetite is way down. Food tastes like paste . . . really

very little taste at all. I’ve even lost weight.Clinician: About how much and over how long a time?Patient: Oh, about 5 pounds, maybe over a month or two . . .

This section of interviewing explores the same region as theprevious interview, but this time the questioning seemed to flow more naturally, generating an in-creasing flow of information, peppered with moments of empathy and requests

by the clinician to hear more about specific symptoms that suggested both interestand caring. The trainee’s questions seemed to relate directly to what the patientwas saying, thus creating a sense that the trainee was ‘‘with’’ the patient.

A further point to consider concerning the expansion of regions is whether ornot, once a supervisee enters a specific content region, the supervisee finishes theentire region before leaving it. Sometimes it is useful to leave regions before com-

pletion (a process called a ‘‘split-expansion’’), and many times it is not. Facilics al-lows us, as supervisors, to monitor this particularly telling trait of the superviseeobjectively and to point out to the trainee whether it was advisable to use a split-expansion with a particular patient at a particular point in the interview.

For instance, while expanding the diagnostic criteria for the generalized anx-iety disorder region, the patient may mention the use of diazepam (Valium). Atthis point, the clinician may choose to expand the medication history, afterwhich he or she can return to the anxiety disorder region to complete its expan-sion. Sometimes a clinician may choose to split even a single expansion multi-

ple times before finishing it. Although they sometimes are indicated, split-expansions often can lead to serious omissions if the clinician does not keeptrack of what information has been gathered and subsequently fails to returnto seek the needed information.

On occasion, a clinician may expand simultaneously two regions whose con-tents are similar in nature. For instance, one could expand the anxiety disorder




region and the affective disorder region in a parallel fashion (called a ‘‘parallelexpansion’’), because the symptoms in these disorders frequently overlap. Suchparallel expansions are a bit tricky: it is easy to miss important data, becausethe clinician must keep track of two sets of diagnostic criteria simultaneously.This task is not always easy and almost never is easy for a novice interviewer.

The overriding point remains the clinician’s need to develop an active andconscious awareness of the data flow while simultaneously creating the sensa-tion of a natural flow of conversation. An understanding of facilics allowsa trainee to do just that. As supervisors we find it useful to remind traineesin an ongoing fashion of the following points regarding expansion of contentregions (an example of the second aspect of facilic supervision: applying facilicsto communicate tips for improved structuring):

1. Generally speaking, an effort should be made to achieve blended expan-sions as opposed to stilted expansions; such blended expansions movewith the patient.

2. Techniques such as split-expansions and brief excursions can be useful aslong as one remembers to monitor the completeness of his or her database,but they need to be used judiciously. Otherwise, significant errors of omis-sion can occur if the interviewer ‘‘gets lost’’ in the wanderings of the patientand does not return to finish compiling important material in prematurelyexited content regions.

3. The interviewer always should attend to engagement on both a verbal anda nonverbal level during the expansion of content regions.

Process RegionsIn addition to focusing on content, thereby gathering a prespecified database,interviewers often need to shift focus to the actual process of the interviewon a meta-level. For instance, while uncovering a drug and alcohol history,an interviewer may inadvertently offend the client. At that point the inter-viewer must attend directly to the engagement process by addressing the poten-

tial anger of the client. In a broad sense, in facilic language, all expansions thatare not content expansions (eg, focused primarily on the gathering of a specificdatabase) are called ‘‘process expansions.’’

Thus classic situations in which one is focusing on the process of the inter-view (eg, specifically enhancing engagement, addressing resistance and anger,and exploring psychodynamic processes or defense mechanisms) are depictedas process regions. In addition, other regions that do not focus primarily ondata gathering but are not directly related to the meta-process of the intervieware also still called process regions. Examples of this type of process region are

periods of crisis intervention or sections of time devoted to providing psycho-education. For purposes of illustration, three of the classic process regions arediscussed in more detail.

‘‘Free facilitation’’ process regions The ‘‘free facilitation’’ process region remains one of the foundations of all in-terviewing. It is the traditional method of nondirective listening. In it, the

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interviewer invests effort in creating an atmosphere that is optimally conducivefor the client to feel safe enough to begin sharing his or her problems. The cli-ent is able to wander freely to whatever topics he or she chooses, while the in-terviewer maintains a nondirective attitude. The major interventions of theinterviewer are usually facilitating head nods, ‘‘uh-huhs,’’ and simple facilitativestatements.

These free facilitation regions can occur at any point in an interview and of-ten are a useful method of enhancing engagement. For instance, during theopening phase of the interview, clinicians frequently use a series of free facili-tation regions. Naturally, most content regions have many attributes in com-mon with free facilitation regions; but a free facilitation region differs in thegoal of its use, which remains the strengthening of the engagement process.The patient may reveal surprising amounts of useful information during theseunstructured facilitation regions, but it is without specific direction by theinterviewer.

A brief example may help to clarify when a section of an interview can belabeled as a free facilitation region.

Patient: I don’t know what’s coming over me. . .I just feel sort of crazy.Clinician: What do you mean?Patient: All my thoughts seem to be mixing like a wet rainbow; distinctions are

blurred, people distorted . . .[pause] I feel this way when I’m with my mother.She

. . ..[pause]

Clinician: Go on.Patient: She always seems so oppressive, so large, like a giant machine always

pushing, always pulling. Honestly, I don’t know where to go with her.Clinician: In what sense?Patient: She wants me to be a success, Lord knows what that means. I think she

wants me to be a college professor or some dean of this or that. But she’s notinterested in what I need, never was. A baby without a bottle, that’s whatI am . . ..

This type of nondirective interviewing frequently helps enhance engage-ment. It also sometimes brings out responses from patients that may hint atan underlying psychotic process as this excerpt illustrates.

‘‘Transforming resistance’’ process regions In a resistance transformation region the interviewer actively attempts todecrease a specific resistance to the engagement process. Such resistance mayarise from any number of factors, including the interviewee’s fears, expecta-

tions, or unconscious processes. The resistance may show itself as an angrycomment or perhaps an awkward and personally intrusive question from theclient. Without a resolution of these resistances, the validity of the subsequentdata and the power of the therapeutic alliance may be jeopardized. In any case,the defining characteristic in a resistance region is the interviewer’s consciousattempt to resolve a resistance shown by the patient.




In the following selection we see an interviewer in the midst of a resistanceregion:

Patient: My boss was really into my work and thinks I may be a little. . .

youknow. . . I don’t really think I ought to go on. Do you have a supervisoraround?

Clinician: You seem concerned about something.Patient: Well, I’d just feel a little better if I were talking to someone a little older.Clinician: What do you think an older clinician would be able to do to help

you?Patient: He’d understand what I’m going through better, that’s for damn sure.Clinician: You know, it’s true I’m younger than you and consequently, I haven’t

experienced the same things, but I can try to gain some understanding of

what you’re experiencing. You could help by telling me a little more abouthow people have been pressuring you about your age.

Patient: Well if you must know, it all started with my wife. She left me about3 years ago for a younger man.

Psychodynamic process regions In a psychodynamic process region the interviewer asks questions in which theclinician is more interested in how and why the patient responds to the clinicianthan in the content of the patient’s answers. In general, the clinician attempts toanswer questions such as the following:

How reflective is the patient?Does the patient have much insight?How does the patient respond to interpretive questions?How good is the patient’s observing ego?

Answers to these questions may help determine the suitability of the patientfor specific types of time-limited psychotherapy, as well as provide insight intothe patient’s intellectual development, ego strength, defense mechanisms, self-concept, or genuine readiness to engage in treatments such as substance-abuse

counseling. To answer questions in a psychodynamic region, the patient mustreflect and offer an opinion.The following excerpt may clarify when a psychodynamic region is occurring:

Patient: My father always kept a strangle hold on me. He wanted to know myevery move. God pity the boy who wanted to take me out. It was like a Ge-stapo interview for the guy.

Clinician: What kind of impact do you think your father’s behavior has had onyou?

Patient: He’s made me scared. I’m afraid of him, and who knows, maybe I keep

my distance from him because of it. . .

Sort of strange, because when I wasa kid I always wanted to be around him. I even would wait for him when hewas at work.

Clinician: Go on.Patient: Oh, it’s sort of silly, but I wondered if he had a toy or something for

me . . . I remember a small doll he brought home once, with big blackeyes. Just a little doll, but important to me.

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Clinician: Go on.Patient: Not too much more to say, except that it’s sort of sad the way things

have turned out between us.

Clinician: What are you feeling as you talk about your father right now?

Here, content is clearly taking a second place to process. The client’s re-sponses suggest a willingness and a certain degree of proficiency at self-explo-ration. This type of region can occur anywhere in an interview, often appearing

between content regions.

The Scouting Region: A Unique Combination of Content and ProcessNow that we have a good understanding of the differences between contentregions and process regions, it is a good time to look at an outlier—the scouting phase. It is a stage of a clinical interview ripe with potential for both problemsand opportunities. The facilic term ‘‘scouting phase’’ is used to describe theopening 7 minutes or so of an interview, in which the interviewer introduceshimself or herself and proceeds with the opening phase of the interview. Thereis a premium on free facilitation regions and the engagement process itself.Open-ended questions and an empathic statement or two are classic foundation

blocks of the scouting phase. On the other hand, as much as the scouting phaseemphasizes the use of process regions, invariably much valuable data will beforthcoming from the client. The clinician does little to structure this data;nevertheless, clients often spontaneously share critical aspects of the databaseearly in the interview. Thus the scouting phase is a unique type of region: itis both a process region and a content region at once, with a relatively equalemphasis on process and data gathering.

Gates: The Pathways of TransitionAs a conversation or an interview passes from one topic to another, differenttypes of transitions occur. In facilic supervision, we refer to the actual state-ments joining two regions as ‘‘gates.’’ Although numerous types of gates exist,

five major forms are the most common: (1) the spontaneous gate, (2) the nat-ural gate, (3) the referred gate, (4) the implied gate, and (5) the phantom gate.An understanding of the use of these gates gives trainees a simple but elegantmethod of gracefully maneuvering an interview.

The trainee’s habitual use of gates—and they generally are used out of hab-it—may well be the single most powerful indication of how conversational orawkward a trainee’s interviews will feel to patients. Helping trainees identifytheir own gating and subsequently helping them master ways of using the othertypes of gates flexibly (because all types of gates have their advantages and dis-

advantages) is, in our opinion, one of the greatest gifts we can give a trainee.Such self-knowledge and the resulting flexibility in style it provides are fre-quently the difference between a trainee who would have gone on to a careerof ‘‘Meet-the-Press’’ interviews and one who has a career of powerfully engag-ing clinical interactions. Let’s take a look at each of the gates and how theymanifest in actual interviews.




Spontaneous gates The spontaneous gate, as its name suggests, unfolds without any effort by theinterviewer. Instead, the gate results from a change in topic unilaterally taken

by the patient. These gates occur when the patient spontaneously moves intoa new region (called a ‘‘pivot point’’), and the clinician proceeds to aska follow-up question in this new region. The patient does the shifting here.The clinician merely follows, sometimes with phrases as simple as ‘‘Tell memore about that,’’ or ‘‘How do you mean?’’ In the following example,a spontaneous gate provides an essentially imperceptible movement out of an expansion of depressive symptoms and into a new content region. See if you can spot it.

Patient: The past 2 months have been so horrible. I think it’s the worst time of mylife. I just can’t get away from the feeling.

Clinician: What feeling are you referring to?Patient: The sadness; the heaviness.Clinician: What else have you noticed when you’re feeling sad and heavy?Patient: Nothing seems worth doing. It’s late November and my yard is covered

with leaves. Usually they’d all be gone into neat little piles, like a little farm,but not now . . .

Clinician: Besides not having energy for chores, do you find you can still enjoyyour bridge club or other hobbies?

Patient: Not really. Things seem so bland. I haven’t even gone to bridge club forseveral months. It is all so different from before. In fact, there were times inthe past when I could barely keep still, I was so active. I was a super dynamo.

Clinician: How do you mean?Patient: Oh, I used to be incredibly active, into bridge, tennis, golf, and every-

thing. It was hard to find people who could keep up with me.Clinician: Did you ever move too fast?Patient: In what sense?Clinician: Oh, sometimes one can get so energized that it gets difficult to get

things done.

Patient: Actually, there were a couple of odd times when people kept telling meto ‘‘slow down, slow down.’’

Clinician: Tell me a little more about one of those times.Patient: About a year ago I got so wound up I hardly slept for almost a week. I’d

stay up most of the night cleaning the house, washing the car, and writingfuriously. I didn’t seem to need sleep.

Clinician: Did you notice if your thoughts seemed to be speeded up then?Patient: Speeded up. I was flying. Everything seemed crystal clear and moved

like lightening. It was strange . . .

In this example, two content regions are discussed sequentially. In the firstregion, the interviewee’s DSM-IV-TR symptoms of depression are being explored. In the course of this exploration, the interviewee brings up a statementthat enters a different diagnostic region dealing with mania. The transitionstatement was, ‘‘In fact, there were times in the past when I could barelykeep still, I was so active. I was a super dynamo.’’

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The interviewer then followed this movement into a region exploring manicsymptoms by simply asking, ‘‘How do you mean?’’ Once within the diagnosticregion of a mania, a blended expansion was begun. This movement into a newtopic was practically imperceptible.

Spontaneous gates create movement that seems unblemished by effort or re-sistance. In this sense, a clever interviewer frequently will make use of suchgates whenever transitions into new regions are desirable. But herein lies a potential pitfall, mentioned earlier when discussing split-expansions: frequentlyit is not desirable to leave a region before it is fully expanded.

In this light, pivot points represent critical areas in which the interviewershould decide consciously whether to redirect the patient gently back intothe current expansion and complete it or move with the patient into the newregion the patient just entered. If the clinician can become aware of such pivotpoints, he or she will gain considerable control over the flow of questioning.One does not and should not follow every pivot point with a follow-up ques-tion into a new region. Once within the body of the interview, if a patient need-lessly wanders out of a content region, it is often best to gently bring them backto finish gathering any missing important information from the region. Suchgentle structuring can significantly decrease errors of omission.

Indeed, the concepts of spontaneous gates and pivot points providesus with a way of conceptualizing wandering interviews in which little in-

formation of importance is uncovered. These interviews occur when theclinician follows pivot points whenever they appear, resulting in a consis-tent pattern of incomplete split-expansions with a subsequently weakdatabase.

Attimesaclinicianmaydecidewiselytofollowapivotpointintoaspontaneousgate even in the middle of an incomplete expansion. Such situations include thefollowing: (1) the patient may have unexpectedly related emotionally chargedmaterial that needs to be ventilated; (2) the patient may have spontaneously men-tioned sensitive material that may best be approached immediately, such as sui-

cidal ideation or incest; and (3) specific memories, such as screen memories,dreams, or traumatic events, may warrant immediate follow-up.

With the use of facilics, supervisors can point out the appropriate and inap-propriate instances of following pivot points into new regions through sponta-neous gates. Indeed, helping trainees become routinely aware of pivot points asthey arise in interviews—providing them a chance to decide consciouslywhether to leave a region or gently refocus a wandering patient back into a region—can be the key in helping trainees to structure interviews effectivelyand sensitively.

It can be a revelation to trainees to learn experientially that clinicians canexercise significant choice as to the structural pattern any given interview willtake as long as the clinician recognizes the pivot points and purposefullydecides whether or not to follow them into new topics through the use of a follow-up question (a spontaneous gate). By understanding facilics, a traineecan learn first-hand that interviewers are not merely at the whim of a client’s




wanderings. Sensitively structured interviews do not just happen—they arecreated.

Natural gates The natural gate consists of two parts: the cue statements and the transi-tional question. The cue statements represent the last one or two sentences(usually the last one) made by the interviewee that may contain contentmaterial that the interviewer can relate creatively to a new region. If the in-terviewer takes cues from these statements to enter a new region, the inter-viewee will feel that the conversation is flowing from his or her own speech,as indeed it is. Such a transition seems both natural and caring to theinterviewee.

The transitional question represents the actual question asked by the inter-viewer that creates a bridge from the cue statement into the new region. As dis-tinguished from the spontaneous gate, the clinician, not the patient, is moving the conversation into a new region.

In the following excerpt we see a transition from the region covering depres-sive symptoms into the drug and alcohol region. This smooth transformation ismade through a natural gate.

Clinician: Have you been able to enjoy your poker games or your shop work?

Patient: No, I just don’t feel like doing anything since I’ve been feeling de-pressed. It’s a really ugly feeling.

Clinician: Tell me more about what it feels like.Patient: Really pretty miserable. Life doesn’t seem the same. I’m tired all the time;

no sleep.Clinician: How do you mean?Patient: Over the past several months sleep has almost become a chore. I’m al-

ways having trouble getting to sleep, and then I wake up all night. I mustwake up five times and it took me 2 hours to fall asleep in the first place.

*Clinician: Have you ever used anything like a nightcap to sort of knock your-

self out?Patient: Yeah, sometimes a drink or two really relaxes me.Clinician: How much do you need to drink to make yourself sleepy?Patient: Oh, not too terribly much. Maybe a couple of beers. Sometimes more

than a couple of beers.Clinician: Just, in general, how many drinks do you have in a given day?Patient: Probably. . .Now, I’m just guessing, but probably a six-pack or two,

maybe three. I hold liquor pretty well. I don’t get plastered or nothing.Clinician: What other kinds of drugs do you like to take to relax?Patient: Well, I might smoke a joint here or there.

In this excerpt, the cue statement was, ‘‘I must wake up five times and it tookme 2 hours to fall asleep in the first place.’’ Note that the patient’s cue statementis still within the region of depression. But the clinician, wanting to change con-tent regions, sensed that this statement could be used as a springboard intoa new topic. The succeeding transition question (indicated by an asterisk)

e64 SHEA & BARNEY



smoothly achieved this desired transition into the drug and alcohol region withthe phrase, ‘‘Have you ever used anything like a nightcap to sort of knock your-self out?’’

From the perspective of the second aspect of facilic supervision—applying fa-cilics to communicate tips for improved structuring—transitions of this sort areseldom perceived as focusing mechanisms, because the patient generally feelsas if he or she brought up the new topic. This type of smooth transition cangreatly enhance a conversational feeling in the interview, slowly bringing thepatient into a more powerful sense of safety and spontaneity. The interview be-gins to take on a self-perpetuating momentum, unique to its own nature.

Fig. 1 demonstrates the immense power of the natural gate. We shall assumethat the expansion of the stressor region has been winding down. The patientthen provides a cue statement that the clinician can use to enter one of anynumber of new content regions as illustrated. The flexibility of the naturalgate is limited only by the awareness and creativity of the clinician.

Referred gates A referred gate occurs when the interviewer enters a new region by referring

back to an earlier statement made by the interviewee. Typical referred gates begin with phrases such as, ‘‘Earlier you had said . . .’’ or ‘‘I want to hearmore about something you mentioned before . . .’’ To the interviewee, a re-ferred gate metacommunicates, ‘‘I have been listening very carefully to you;moreover I want to learn more about something you said to see if I can

help.’’ It is a wonderful example of a structuring tool that is also an engagementtechnique. It allows the interviewer to enter a fresh region smoothly at almostany place in an interview. It also is extremely useful for re-entering a regionthat was not completely expanded earlier. Structurally, a referred gate lacksan adjacent cue statement, because the cue has been taken from an earlier seg-ment of the interview.

Stressor Region

Pt.] My arguments with my

husband are so bad that

I just don’t know what’s

happening anymore.

a

b

c

Lethality Region

Borderline Personality

Region

Depression Region

Alcohol & Drug

Region

d

Fig. 1. Natural gates utilized as smooth transitions. Transition questions: (a) With all these ten-sions mounting, have you had any thoughts of wanting to kill yourself? (b) How have all thesestresses affected your mood? (c) With all these stresses, have you been drinking at all in aneffort to calm yourself? (d) Some people hold all their anger in and others really let it out,maybe even throwing things like glasses or plates. How do you handle your anger? (From

Shea SC. Psychiatric Interviewing: The Art of Understanding, 2nd edition. Philadelphia: WB

Saunders Co., 1998; with permission.)




In the following illustration we enter the interview at the end of a psychody-namic process region in which the patient’s feelings about his siblings have

been explored. As this process region winds down, the interviewer, by referring to something said earlier in the interview (but not shown in this transcript) en-ters the content region dealing with psychotic phenomena by using a referredgate.

Clinician: What was it like for you when your brother would come home fromcollege?

Patient: Sort of odd; a little bit like a trespass. You see, when he was gone I hadthe room all to myself, even the phone was mine alone. As soon as he cameback, boom, the room was his again.

Clinician: What other feelings did you have?Patient: Some excitement. I really did look up to him, and when he’d come

home he’d tell me all about college, frat parties, smoking grass; and itwas exciting.

*Clinician: Earlier you had told me that sometimes when you were alone you’dhave scary thoughts. Tell me a little more about those moments.

Patient: Okay. It’s sort of like this. I might be sitting late at night listening to somemusic and things seem sort of weird, almost like something bad is going tohappen. And then I have thoughts that keep coming at me and they tellme to do things.

Clinician: Do the thoughts ever get so intense they sound almost like a voice?Patient: They are voices. They seem very real. In fact, sometimes I try to cover

my ears. I just don’t know. I don’t know. . .

Referred gates, such as the one indicated by the asterisk in this dialogue, areunobtrusively powerful. They can be used to enter new regions essentially atwill and to re-enter incompletely expanded regions. Clinicians can use referredgates to enter potentially disengaging regions (eg, the cognitive mental status)gracefully.

While asking questions about orientation and checking digit spans or serial

sevens, novice clinicians frequently worry that patients will feel insulted by thesimplistic nature of the questions. To this end, they may use phrases such as,‘‘I’m going to ask you some silly questions now, I hope you don’t mind,’’ or‘‘Now I have to ask you some routine questions that I have to ask everybody.’’These phrases usually are accompanied by an apologetic tone of voice or aninsecure rustling of the clinician in his or her chair.

The irony of such introductions lies in the fact that, rather than dispelling anxiety in the patient, they sometimes create it. The patient senses that the cli-nician feels insecure with the subsequent questioning. All that remains for the

patient to wonder is why the clinician needs to apologize. What do these rou-tine questions mean, and why does a professional ask questions if they aresilly? In short, the clinician’s sudden obsequiousness signals to the patientthat something odd is afoot.

Here one of the many uses of the referred gate becomes apparent. Byreferring to earlier statements by the patient concerning problems with

e66 SHEA & BARNEY



concentration or thinking, the interviewer can enter the cognitive examinationsmoothly and without a need to apologize. Quite to the contrary, the inter-viewer’s interest indicates a sincere concern to the patient as well as a displayof professional expertise. The use of the referred gate metacommunicates to thepatient that these questions are being asked for a specific reason—to clarify col-laboratively the degree of cognitive impairment, a point of interest to both theclinician and the patient. Let us take a look at such an approach in action. Thepatient is suffering from an agitated depression and had complained earlier inthe interview of ‘‘problems concentrating’’:

Patient: Overall, I know it’s all my fault. I should never have retired, it’s ruinedeverything. But life goes on. I only hope I feel better some day.

Clinician: What do you see for yourself in the future?Patient: Hopefully, some pretty good stuff. I’ve always wanted to travel and mywife is interested in doing so as well, so, I think we will probably do a littletraveling. And, I also used to paint a little bit, maybe I’ll do a little of that too.

Clinician: That sounds pretty neat. I hope it works out for you.Patient: Yeah, me too.Clinician: You know, a little earlier, you had mentioned that one thing that was

bothering you was your lack of concentration and some problems withmemory. I have some questions that would give us both a clearer idea exactlyhow much your concentration and thinking have been affected by your

depression. Some of the questions will be very simple, while some of themmay get fairly challenging. Why don’t we start with some of the simpleones first?

Patient: Sure.Clinician: What day of the week is this?Patient: I think it’s Wednesday.Clinician: That’s correct. What city is this?Patient: Pittsburgh.

This interview dyad has gracefully moved into the cognitive mental status

examination with a sense of purpose and no hint of uneasiness on the partof the clinician.

Phantom gates A phantom gate seems to come from nowhere. It lacks a cue statement and alsolacks previous referential points, unlike referred or natural gates. In short, it

jolts the spontaneous flow, as the following example shows:

Patient: I haven’t felt the same for months. I’m always down and I’m sick of it.Clinician: What does it feel like to be down?

Patient: Very unsettling. I’m like a slab. I don’t want to do anything. I miss doingthings with my best friend, silly as that may sound. I really haven’t been thesame since she died.

*Clinician: Was your father an alcoholic?Patient: No . . . [pause] I don’t think he was. He drank every once in a while.Clinician: What about your brothers, sisters or blood relatives? Have any of

them had drinking problems?




Patient: Not that I know of.Clinician: What about depression? Have any of your relatives been depressed?

This interviewer’s sudden leap into the family history region certainlyseemed abrupt and ill timed. Obviously, if such phantom gates (indicated bythe asterisk) occur frequently throughout an interview, engagement can be se-riously hampered. Even in milder forms, they can quickly produce the ‘‘Meetthe Press’’ feeling discussed earlier, especially if accompanied by stilted expan-sions. They often pop up toward the end of interviews, when interviewers sud-denly realize there are several things they forgot to ask, and they are running out of time. If indeed important regions have been incompletely expanded, a supervisor can point out that a referred gate, rather than a phantom gate, usu-

ally can be used without substantially interrupting the flow of the interview.In the meantime, a phantom gate placed here and there probably will notcause much of a problem, especially if the engagement seems to be high, andthe content of the question is not sensitive in nature. In general, however,one should avoid phantom gates, because it seems senseless to risk damaging the flow of the interview.

Implied gates To complete our summary of transitions used during the body of the interview,

we turn our attention to implied gates. Implied gates are structurally similar tophantom gates: they do not cue off the patient’s immediately preceding state-ments; they do not refer back to earlier statements; and the clinician, not theclient, initiates the movement into the new topic. There is one important differ-ence between an implied gate and a phantom gate: the implied gate enters a region that is topically similar to the previous region.

Put slightly differently, in an implied gate, the movement into a new region ischaracterized by asking a question that seems to be generally related to the regionalready under expansion. Thus, it is somewhat ‘‘implied’’ that the interviewer is

simply expanding a topic already germane to the interviewee. Consequently,implied gates tend to be much less disruptive to flow than phantom gates.In the following example, movement is made from the region dealing with

immediate stressors into past social history. The transition (indicated by an as-terisk) seems relatively smooth, an effect that is secondary to the similarity incontent between these two regions.

Patient: We’re living in a fairly nice house now. It has three bedrooms and a cou-ple of acres. Believe me, we need the space with our four kids.

Clinician: How are the kids getting along?

Patient: The two oldest, Sharon and Jim, get along pretty well, on differenttracks. They stay out of each other’s way. But the two little ones—oh my!They live to torture each other . . . Pulling each other’s hair, yelling, scream-ing. It’s a zoo.

Clinician: I’m wondering if, with all those mouths to feed, money is a problem?Patient: In some respects, yes; but my husband is a lawyer and is doing well. In

fact, if anything, our income has increased recently.

e68 SHEA & BARNEY



*Clinician: Tell me a little bit about what it was like for you when you grew upback in Arkansas.

Patient: First of all, I came from a large family of eight children. So we some-

times, many times, had to do without. I remember all the hand-me-downs,and, believe me, I appreciated them. My mother was a loving woman, butbeaten down by life. She was tough, but her pain showed through.

Clinician: Do you remember a specific time when her pain showed through?Patient: Oh, yes. I was about 5, I think, and . . .

For purposes of review, keep in mind that, unlike a natural gate, an impliedgate does not cue directly off the preceding statement. Furthermore, unlike a re-ferred gate, the interviewer does not directly refer back to earlier statements.And, in contrast to the phantom gate, the implied gate seems to fit in fairly nat-urally with the current flow of the dialog. Indeed, when the newly entered re-gion appears very similar to the preceding one, an implied gate is practicallyimperceptible and rivals a natural gate for smoothness of transition.

As the regions connected by the gate increase in disparity, the implied gate becomes progressively more abrupt. Thus, with regard to smoothness, impliedgates range on a continuum between natural gates and phantom gates. Whenthe two regions are closely related, implied gates approach the gracefulness of natural gates. On the other hand, if the topics are poorly related, an impliedgate may approach the awkwardness of a phantom gate.

At this junction, we have completed our introduction to the core terminologyof facilics. Facilics provides a simple language with which to follow the complexstructuring techniques of both interviewers and those they supervise. Once a cli-nician understands the principles of facilics, the interview can be developed andaltered almost at the whim of the interviewer. These tricks of the trade can in-crease the engagement with the patient, the effectiveness of the data gathering,and ultimately the validity of the database itself.

Initiated by the conscious decisions of the interviewer, the clinical dialoguecan unfold in a more graceful and effective manner. With each unfolding,

the initial resistance of the interviewee gradually recedes, because the inter-viewer, instead of opposing this resistance, moves with it. Using natural gatesand blended expansions, the trainee can create interviews that move with thegentle dynamics of a collaborative conversation. The patient feels morerelaxed, defenses drop, and the interviewer discovers a rich field of pertinentinformation opening before him.

Once familiar with the basic facilic terminology, a supervisor can map out anentire interview from front to back. We have not found any structural situa-tions that cannot be mapped using this system. (There are a few facilic anom-

alies, such as ‘‘introduced gates,’’ in which the clinician literally states, ‘‘I’d liketo spend some time asking about . . .,’’and ‘‘observed gates,’’ in which the cli-nician makes note of a client’s nonverbal communication, as with, ‘‘It lookslike you are starting to well up,’’ for which there is not space for a thoroughdiscussion in this article). Armed with this introduction, you are ready to usethe system. There is only one more critical aspect of facilics that you need to




know before beginning: the facilic shorthand. Let’s take a look at it. It is delight-fully straightforward.

AN INTRODUCTION TO THE FACILIC SCHEMATIC SYSTEM: A SHORTHAND FOR SUPERVISORSFacilic schematics allow a supervisor to make a permanent record of the super-visee’s interview quickly and provide a concrete, visual springboard for imme-diate feedback. The flow of the trainee’s interview can be captured graphicallyin a way that brings the interview to life for the trainee while presenting an eas-ily understood map of the trainee’s explorations of major topics and the tran-sitions used to connect them. This system of ‘‘shorthand’’ can be used in directsupervision, class discussion, and videotape supervision.

The idea for the system originated from a most unlikely source. One hotsummer day I was perusing a book on modern dance. To my surprise,when I came upon the Appendix, I found several ‘‘dance notation’’ systems cre-ated by various choreographers to capture on paper the flows of their dances.Thus, a dance created at a summer festival, once notated, could be resurrected

by an entirely new group of dancers a decade later.If the complicated movements of a modern dance could be encoded simply,

surely the structural movements of an interview could be represented as well.

Facilic schematics were born.Subsequently, these facilic schematics have become one of the most popular

aspects of the facilic system, and some would say they are key to its practical appli-cation in supervision. We certainly have found them to be invaluable in training.

Two complementary systems are available. In a longitudinal facilic ‘‘map,’’the interview and its transitions are followed from start to finish chronologi-cally. This technique is the backbone of the system, providing a detailed buteasily followed description of the trainee’s expansions, gates, and flow. Wemake a longitudinal map for our trainees whenever we have an opportunity

to view their interviews directly, whether within the interview room, behinda one-way mirror, or by videotape.

The second system is called a ‘‘cross-sectional map,’’ a fancy name for a sim-ple pie diagram, which depicts the interview as being divided into four quartersof time. These cross-sectional maps do not track the specific structural tech-niques of the trainee but do allow a graphic look at how the trainee managedtime, providing a powerful complementary tool to the fundamental longitudi-nal facilic map.

Making a Longitudinal Facilic Map: Tricks of the TradeBefore beginning our description of facilic schematics, we should mention that,on rare occasions, a student may misconstrue the purpose of the system, think-ing that the schematics are a graphic system drawn by the interviewer during the interview to track the information he or she has gathered. Remind your stu-dent that facilic symbols are not intended to be made by the interviewer: they

e70 SHEA & BARNEY



are a shorthand for the supervisor, who later will share the map with the stu-dent after the interview.

The first convention is that a content region is shown as a rectangle, with theabbreviated name for the region within it. Thus, as you follow the flow of theinterview, if the trainee is exploring the DSM-IV-TR diagnosis of major depres-sion, you simply jot down a rectangle with ‘‘Maj. Dep.’’ written inside it.

The degree of thoroughness in expanding any given content region is de-picted by slash marks at the corners of the rectangle. One slashed corner rep-resents that the trainee explored 25% of the needed information, two slashedcorners represent 50%, three slashed corners represent 75%, and four slashedcorners represent a completely expanded region. Thus, if the trainee leaves theregion of major depression prematurely with 50% of the criteria not explored,this split-expansion is noted simply by making a single slash mark at any twocorners of the rectangle as soon as the dyad leaves the area. This notation im-mediately tells the supervisor that the resident needs to return to this region atsome point later in the interview to finish the expansion to avoid errors of omission.

You always makes these slashes depending on the database you, as a super-visor, think should be covered within the specific region. The completeness isdetermined by the task at hand. Keep in mind that the requisite data for thetask at hand can vary depending on the setting and type of interview being

done by your trainee, even though the content region is the same.For example, in a classic initial 50-minute interview, when expanding the re-

gion related to major depression, it would be expected that most of the criteria for a major depression would be covered. If the interviewer touches on all thesecriteria, the supervisor would mark the rectangle with four slashes representing 100% completion of the task at hand.

In a busy emergency room, in which the entire interview might only be 20minutes, it would be inappropriate for the clinician to cover all these criteria.Instead, criteria for several major depressive symptoms (with a close look at

suicidal ideation) would be covered, with a special emphasis upon the severityof the symptoms, because it is the symptoms’ severity that may best help theemergency room clinician make a safe triage for the patient (outpatient versusinpatient).

When supervising an emergency room interview, if the trainee covered onlya handful of the symptoms of a major depression but carefully explored theirseverity and the client’s extent of suicidal ideation, once the trainee left the re-gion of major depression the supervisor would make four slashes, indicating that all the appropriate data points had been covered for the task at hand

(an emergency room assessment) . Indeed, if in that hectic emergency room,the clinician carefully covered all the criteria for major depression (thus losing precious time on data that will not help with the triage of the patient), the su-pervisor would make a fifth and possibly sixth slash on the rectangle indicating that too much information was gathered for the task at hand. The residentmust learn to be more flexible in making data-gathering decisions.




As you follow split-expansions, when the dyad re-enters the expansion yousimply draw a rectangle again, with the appropriate topic abbreviated inside,and immediately mark the same number of slashes as it already had, because,obviously, that amount of data has already been covered. Once the dyad leavesthe region, the supervisor adds slashes as deemed appropriate for any newinformation that has been covered.

You can see that if a trainee has a tendency to expand regions incompletely,resulting in numerous errors of omission at the end of his or her interviews,this problematic tendency will be displayed clearly in the facilic maps bya bevy of incomplete expansions. The power of the facilic map to highlightthe problem visually helps residents see the extent of the problem more readilyand, ideally, be motivated to change it.

Process areas (such as psychodynamic inquiries and areas in which resistanceis transformed) are represented by circles. Once again the correct title of theprocess region is abbreviated within the circle as with ‘‘Dynam.’’ or ‘‘Resist.’’

The scouting phase is indicated by the combination of a rectangle and a circle(eg, a rectangle with a half circle on each end as shown in the illustrative facilicmap) (Fig. 3).

All gates are depicted as shown below in Fig. 2 and are placed between twosuccessive content or process regions to form a continuous map of linked fig-ures that accurately represent the flow of the interview:

The entire interview and its flow can be captured permanently using thissmall set of symbols. In contrast to writing several sentences to capture thecomplexities of a single transition by a trainee, the facilic shorthand allowsthe supervisor to minimize the amount of time spent making supervision notesand focus more attention on the interview itself.

Spontaneous Gates

Natural Gates

Referred Gates

Implied Gates

Phantom Gates

Introduced Gates

Observed Gates

Fig. 2. Transitional gates. (From Shea SC. Psychiatric Interviewing: The Art of Understanding,2nd edition. Philadelphia: WB Saunders Co., 1998; with permission.)

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We think that, with some practice, you will be pleasantly impressed with thedegree of complex information about the trainee’s structuring style that can becaptured quickly.

With videotape facilic supervision, the supervisor first watches the tapealone and subsequently reviews it with the trainee. When first watching the tape, the supervisor uses the facilic schematic system to note the flowof the interview while adding comments about any other technical aspectsof the interview, such as engagement techniques and psychodynamic con-cerns. The duration of the interview in minutes and the videotape counternumber (if available) are noted periodically. This ability to identify sectionsof the videotape that represent particularly important teaching points allowsthe supervisor to turn to them quickly during the supervision itself, maximiz-ing the quality of the supervision hour. The system also provides a permanentoutline of the trainee’s interview that can be referenced in future sessionsof supervision by both the supervisor and the trainee. An example of partof a longitudinal analysis of an actual trainee’s interview is shown inFig. 3.

The asterisks represent areas of videotape that it may be useful to view withthe trainee. This clinician tends to overuse abrupt transitions (as evidenced bymany phantom gates) and to leave content regions prematurely (as evidenced

by many split- and never-completed expansions). These errors may weaken the

thoroughness of the database needed in this particular style of intake assess-ment, in which a complex triage was to be determined and a full diagnosticevaluation was requested. Numerous positive comments highlighting the skillsof the clinician also were made in the actual supervision.

The facilic map merely provides a framework for discussion. In fact, as illus-trated in Fig. 3, another advantage of the system is that it provides an easilyaccessible visual record that helps the supervisor remember points of interestrelated to all aspects of the interview (not just points related to structuring), in-cluding nonverbal communication, psychodynamic considerations, and

methods of handling resistance.To annotate points in the interview that the supervisor intends to com-

ment on later or to describe the exact wording of the interviewer’s gates,a circled letter of the alphabet is placed on the facilic map with the accompa-nying supervision point listed below the map as shown in Fig. 3. The super-vision itself is characterized by spontaneity, humor, and discussions of bothdynamic and personal feelings related to the interview. The trainee also mayrequest that certain areas of the tape be viewed in case the trainee had ques-tions about areas of the interview the supervisor did not highlight.

The second type of facilic map, a cross-sectional schematic, provides an illu-minating view of the actual use of time in the interview. Thirty minutes of a cross-sectional analysis are shown in Fig. 4.

Facilic maps, whether longitudinal or cross-sectional, help make interviewing skills that at first glance often appear nebulous and confusing to a young traineemore real and manageable. We have found that the behavioral specificity of the




system enhances the likelihood that tangible and enduring changes in inter-viewing technique will result from supervision. These tangible changes, onceperceived by the trainee, often trigger a renewed fascination and respect forthe art of interviewing itself.

0:00 tape

0 mins.

9:33

11 mins

15:30

12:96

16 mins10:41

17:60

23 mins

34 mins

30 mins

Somatic comp.

Anxiety Symp.

Referral

Process Dynamic

a b

Drug

& Alc.

e

Past Psych.

Hx. Dynamic Meds.

d c

Medical

HistoryFam. Hx. Social Hx. Premature

Closing

Depression Dynamic

Fig. 3. Counter settings.I. Transitions (gates)a. What made you come to our clinic today?b. What were some of your feelings about coming here today?c. What role do you think your actions play in some of these problems?d. Have you ever seen a psychiatrist before?e. Are you a problem drinker?

II. Teaching points1. Scouting phase is appropriately unstructured and free-floating but is too long2. Too much detail and time spent in the referral process region3. Good psychodynamic questioning.

4. Decrease use of phantom gates (ask clinician what he was feeling at this point of theinterview)5. Explore use of chronology as a reference framework6. Good use of empathy: ‘‘Sounds like the world was caving in on you back then’’7. Use behavioral incidents when delineating the drug and alcohol history. I think this

patient was providing invalid information. (Also comment on note taking—toomuch.)

8. Here’s a series of type A validity errors including multiple questions and negativequestions

(From Shea SC. Psychiatric Interviewing: The Art of Understanding, 2nd edition. Philadelphia:WB Saunders Co., 1998; with permission.)

e74 SHEA & BARNEY



IMPORTANT NOTE: At this point, we recommend pausing from the bodyof this article and turning to the Appendix. There we have provided a pro-grammed text that gives the reader a chance to practice using facilic schematics.This exercise will expand and consolidate your understanding of facilic sche-matics in a way that we hope is both fun and efficient. After completing the pro-grammed text in the Appendix (which requires about 40 minutes), you will

have a significantly better, hands-on understanding of the principles of facilicsupervision and the use of the facilic shorthand. PLEASE COMPLETETHE PROGRAMMED TEXT IN THE APPENDIX OF THIS MONO-GRAPH BEFORE PROCEEDING.

TIPS AND STRATEGIES FOR USING FACILIC SUPERVISIONMORE EFFECTIVELY In closing our introduction to facilic supervision, we want to comment on a few

tricks of the trade that we have found useful over the years. These tips include:

1. Preparing the trainee to use the system effectively2. Using past facilic maps to re-enforce progress3. Variations on making longitudinal facilic maps4. Common structuring errors made by trainees5. Combining facilic supervision with role-playing and other educational tools

60 min

45 min

Scouting Phase

Referral Process

Dynamic Exploration

Medications

Dynamic Exploration

Past Psychiatric History

Drugs and Alcohol

Medical History

Family History

Social HistoryPremature Closing

30 min

Fig. 4. Cross-sectional schematic. (From Shea SC. Psychiatric Interviewing: The Art of Under-

standing, 2nd edition. Philadelphia: WB Saunders Co., 1998; with permission.)




6. Using the presence of phantom gates to spot emotional or countertransferen-tial responses in trainees

7. Using facilic schematics in a classroom setting

Preparing the Trainee to Use the System Effectively To help prepare the trainee to use the system, we begin by having thetrainee read the chapter from Psychiatric Interviewing: the Art of Understanding [6]mentioned earlier in this article. We recommend providing a brief, informaldidactic presentation on the topic as well. After the reading of the chapterand the didactic follow-up, we strongly recommend providing the traineewith the self-programmed text provided in the Appendix of this article. Wehave used this programmed text with residents regularly, and it is well received.

In addition to being read by a single resident, the programmed text can bedone together as a group as part of your didactic presentation on facilics. Ina group setting a selected resident draws his or her answer on a whiteboard fol-lowed by a group discussion as to its correctness. By the end of a single session,we have been pleasantly surprised how well the residents know the system, al-lowing its rapid use in individual mentoring.

We also recommend that, before using facilics in supervision, you ask thestudent to draw the symbols for the different gates while you watch. If thestudent cannot draw the symbols, the student does not really know the sys-

tem and will not get much out of the supervision (but the student probablywill pretend to follow what you are saying). By informally testing the stu-dent’s understanding of the system before using it, you can spot foggy areasof understanding and provide immediate education to clarify the system.

Using Past Facilic Maps to Re-enforce ProgressWe want to emphasize the usefulness of keeping a file with all of the facilic mapsgenerated during the course of longitudinal supervision. An occasional reviewof this file by the supervisor can significantly increase the objective tracking of

progress, jar the supervisor’s memory of interviewing techniques that were go-ing to be addressed but may have gotten ‘‘lost in the shuffle,’’ and suggest mo-ments when past files can be shared productively with the trainee to show thetrainee areas of improvement in a graphically concrete fashion.

By way of illustration, let us picture a trainee who, at the beginning of theyear, frequently follows wandering patients, leaving content regions prema-turely, with the result that there routinely are major gaps in the trainee’s data-

base at the end of the interview. As mentioned earlier, this problem would bestrikingly apparent in the facilic maps of these interviews (incomplete split-ex-

pansions throughout the map). Now let us picture that, as the year proceeds,the trainee makes significant progress in correcting this problem.

In such situations, by pulling out past facilic maps the supervisor can provideimmediate, visual, and compelling positive feedback with comments such as,‘‘Mary, just look at your earlier interviews where you were often missing important information. Split-expansions all over the place. Now take a look

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at the interview you just did. Fantastic! Every single region was explored fully.Four slashes everywhere! You can really feel good. You have made excellentprogress in your ability to gather a comprehensive and useful database sensi-tively, and it is your patients who will benefit.’’

Variations on Making Longitudinal Facilic MapsThe facilic mapping system can be used any way you see fit. We invite flexi-

bility. Facilic schematics are a tool to be fashioned as you choose.For instance, when making a longitudinal facilic map, we prefer making the

map as described earlier, in which the facilic map is placed at the top of the firstpage, and annotations are placed below the map.

One of our colleagues prefers a different approach. He marks out a column

on the left-hand side of his supervision notes page. As the interview proceeds,he follows the facilics by writing schematics down the column (not across thepage). As he goes down the column, he usually has room to mark one gate andthe region into which it led per line. Directly to the right of these facilic sche-matics, he makes all of his notations, annotating the interview as it proceeds.Such a system has advantages and disadvantages. You can experiment andsee which style of placement of the facilic maps works best for you or bestfor your trainee.

Common Structuring Errors Made by TraineesCertain errors in structuring that we find to be particularly common with res-idents are the focus of the fourth tip. Sometimes, such as when we are review-ing a videotape and tracking its facilics, we have found it useful to have a list of these ‘‘errors to be on the look-out for.’’ We thought you might find the listuseful. Feel free to add other common errors to it.

1. Scouting phase errorsa. Scouting phase is too short—trainee is structuring prematurely be-

fore engagement is secured.b. Scouting phase is too long—a very common error in which thetrainee lets the patient ramble on far too long before beginningto structure effectively. We have seen scouting phases go on for30 minutes!.

2. Expansion errorsa. Trainee uses stilted expansions.b. Trainee uses too many split-expansions and does not return to gather

important information.3. Gating errors

a. Trainee does not recognize pivot points and therefore does not takean active part in structuring the interview.b. Trainee uses too many phantom gates (the ‘‘Meet the Press’’ inter-

view) when natural and referred gates could be used much more ef-fectively to create a conversational flow.

c. Trainee does not use enough natural and referred gates on a routinebasis.




Combining Facilic Supervision With Role-Playing and Other EducationalToolsThe power of facilics to enhance videotape supervision has already beendiscussed.

In addition, facilics provides a particularly useful method for annotating aninterview while you are watching it live (either in the room with the interview-ing dyad or behind a one-way mirror). During such supervision, we sometimestake a break from the interview (patients always are forewarned that such

breaks may occur for supervision purposes), share with the trainee (outsidethe room) the graphics of his or her facilic flow, make suggestions for change,and then have the trainee return to the room to practice implementing the sug-gested changes. Similarly, facilic maps can be used with the ‘‘bug in the ear’’

method commonly employed in family and group supervision from behindone-way mirrors.

Another advantage of actually being in the room with the resident is that thesupervisor has the chance to demonstrate more effective facilic structuring techniques directly by interacting with the patient. Such modeling can be a pow-erful learning experience for a trainee. Thus, after pointing out (in a breaktaken outside the interview room) with the facilic diagrams that a patient iswandering, the mentor can offer to go back in and act briefly as the interviewermodeling directly how to structure an overly loquacious patient effectively.

Facilics also can be coupled effectively with role-playing techniques. If a res-ident persistently uses stilted expansions when exploring diagnostic criteria, thetrainer can use reverse role-playing (in which the student plays the client, andthe trainer conducts the interview) to model the technique of using a blendedexpansion. (See the article by Barney and Shea in this issue for a guide toeffective role-playing techniques such as reverse role-playing.) Sometimes beforemodeling the correct method, we actually use a series of phantom gates (stiltedexpansion) to let the trainee see how unpleasant such an expansion feels. Thisdemonstration highlights, by contrast, the subsequent modeling of the blended

expansion. After effective modeling, the student can practice being the inter-viewer, using blended expansions with various patients that we present withdiagnoses ranging from major depression to posttraumatic stress disorder.

Let us wrap up with an example of one of our favorite uses of facilics in combination with both videotape and role-playing: helping residents who rely ex-cessively on phantom gates discover experientially alternative and moreconversational ways of making transitions. If you spot a phantom gate onthe videotape, you ask the trainee if he or she can think of a gate that wouldprovide a smoother transition, usually a natural gate or a referred gate. If

the trainee can create a more conversational gate, you provide positive feedback on the suggestion and immediately have the trainee try out the more en-gaging gate by directly role-playing the interview segment with the patient justseen on the videotape.

If initially the resident cannot generate alternative gates, you can provideconcrete examples of smoother gates and demonstrate them by a reverse

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role-play (you play the clinician, and the trainee plays the patient). After youmodel the alternative type of gate, you have the trainee practice the techniqueusing standard role-playing in which you play the patient. In this fashion, facilicsupervision, videotape, and role-playing often can be used together quitepowerfully.

Using the Presence of Phantom Gates to Spot Emotionalor Countertransferential Responses in TraineesIf a trainee who seldom used phantom gates during previous observationsuddenly uses one for no apparent reason, it sometimes indicates that thetrainee, at an unconscious level, did not want to continue exploring the topic.For example, when a trainee who usually creates nicely flowing interviews us-

ing natural and referred gates starts exploring substance abuse, he or she mighttend to short-circuit the expansion abruptly with a premature exit using a phan-tom gate. In such situations, you can show the trainee the segment of the vid-eotape where the phantom gate was used and ask what the trainee wasexperiencing, a technique known as ‘‘interpersonal process recall’’ [7]. The re-sulting discussion may reveal important information (eg, that the trainee wasabused by an alcoholic father) that is useful for the trainee to understandand ultimately bring to resolution (in work with one of the trainee’s psycho-therapy supervisors, where this type of information is more typically processed,

or perhaps in personal therapy).

Using Facilic Schematics in a Classroom SettingFacilic shorthand can be a popular tool with groups of students in a classroomsetting in which videotapes or live interviews are being watched and discussed.The class can map out the facilics of the interviewer while the interview is doneor the video is watched.

During subsequent discussion, different students can be asked to draw thefacilics of certain parts of the interview on a whiteboard. The class then can

use this visual as a springboard for discussion: ‘‘How do you guys think thisgate worked here? Does anybody have any other ways of maybe making this transition? Could you draw that alternative way up on the board here?What do people think of Mary’s idea of using a referred gate here instead of an implied one? Which gate feels more conversational to you?’’ I have foundsuch use of facilics to be excellent in generating animated classroom discussionand interaction.

SUMMARY We hope you find facilic supervision to be as enjoyable and effective to use aswe have over the years. It provides a lens for studying and understanding oneof the most complex of interviewing tasks, gathering large databases ina timely and sensitive fashion. As stated in the introduction, every clinical in-terview is as complex as a play, vastly more unpredictable, and potentially lifechanging. The skilled use of facilic supervision and facilic schematics can




optimize the likelihood that trainees understand the dynamics of these playsand that they can create stages on which compassion and healing can emergemore easily.

APPENDIX

EXERCISES FOR CONSOLIDATING THE UNDERSTANDING ANDUSE OF FACILIC SHORTHANDThe following 12 exercises, adapted from a manual created at the Training In-stitute for Suicide Assessment and Clinical Interviewing [8], present excerptsfrom different interviews, exactly as you might encounter them while observ-

ing a supervisee interviewing live or watching a previously videotapedinterview.

Below each exercise (or on a separate piece of paper if viewing this articlefrom our Web archives), draw in the appropriate schematics for the first region

being explored, the gate used by the student as the region is left, followed bythe correct schematic for the subsequent region being entered.

Remember that the regions can be either of the content type (signified bya rectangle) or the process type (signified by a circle). No matter which typeof region you draw, be sure to abbreviate within it the type of content or pro-

cess region that it happens to be.Use the appropriate symbols for the gates, as shown earlier. This process is

exactly the one you will follow when using the shorthand during actual super-vision sessions. As an aid to get you started, an asterisk appears before theinterviewer statement that is a gate. In the following exercises, the only thing that you cannot indicate is the completeness of the expansions of the contentregions (normally done by placing slashes at each corner of the rectangle),

because you are not shown enough of the dialogue in each region to makesuch a determination.

This section is designed as a programmed text to maximize the learning ex-perience for the reader. Each exercise is followed immediately by the correct an-swers and a brief explanation as to why they are correct. We hope you willenjoy the exercises and that they are as much fun to do as they were to create.

Exercise #1Patient: I’ve been feeling very sad. . . what with my wife’s illness and all the rush-

ing back and forth to the hospital for radiation therapy, it’s tough; no realrest.

Clinician: Yea, it sounds tough, and it sounds like you’ve been a great supportfor your wife. I’m wondering how it’s impacting on your energy.Patient: What energy? [patient smiles]Clinician: And how about your concentration?Patient: As you can imagine that’s pretty bad too. You know, I try to avoid cry-

ing, because I want to be strong for her, but its tough.Clinician: I bet you can’t sleep either. Is it rough to fall asleep?

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Patient: Oh yeah; I’d say it takes a couple of hours, unless I take some of myclonazepam.

*Clinician: Roughly how much clonazepam are you taking a day?

Patient: I think it’s one tab three times a day.Clinician: Do you know how many milligrams each tab is?Patient: Yea, I think it’s 5.0 mg, no, no, it’s 0.5 mgClinician: What other medications are you on?Patient: Oh, I got a bunch. I’ve been taking Cymbalta for a couple of months.

Directions Draw the first and second region connected by the appropriate gate below.

Answer to exercise #1Depression content region followed by a spontaneous gate into the contentregion of the medication history as mapped below (Fig. 5).

Discussion In this exercise we see a nice example of an interviewer recognizing an oppor-tune time to enter the medication history, because the patient introduced thetopic by mentioning his clonazepam. Notice that it is the patient who broughtup a new region spontaneously by mentioning the medication. The interviewerthen simply used a follow-up question, ‘‘Roughly how much clonazepam areyou taking a day?’’ that functioned as a spontaneous gate. Most likely, oncewithin the topic of the patient’s medication history, the interviewer will finishit fully using a blended expansion. If the diagnostic region of depression hasnot been completed (a split-expansion for that topic), the interviewer coulduse a referred gate back into the depression region to complete the diagnostic

exploration of depression after having explored the patient’s medication historythoroughly.

Exercise #2Patient: It’s been a long haul. Besides all those short hospitalizations, I also

wound up in the State Hospital in 2006.

DEP. MED. HX.

Fig. 5.




Clinician: How long were you there?Patient: Oh, about 3 months.Clinician: Any other times you’ve been in a hospital specifically for your

depressions?Patient: No, that about does it. When I was at the State Hospital, I seemed to get

a little better; I’m not really certain why. Maybe it was something they did.*Clinician: Have you felt like people are out to kill you?Patient: No, not really.Clinician: What about hearing voices?Patient: I don’t think so, except maybe a time or two.Clinician: Tell me more about that.Patient: A couple of times back home, maybe late at night I’d be watching TV,

and I’d think I’d hear my son call my name.

Clinician: What would he say?Patient: Oh, he’d just call out my name.Clinician: Have you ever felt like people were poisoning your food?


Answer to exercise #2 Past psychiatric history followed by a phantom gate moving into the contentregion of psychosis (Fig. 6).

Discussion In the first section of this excerpt, the patient was describing his previous his-tory of treatment related to his depressions. He was relating some past relief that occurred while being at the State Hospital when—out of nowhere—the

student asked about paranoia. As with all phantom gates, no cue statementsuggesting the presence of a new region to explore was present. The studentunwittingly compounded the awkwardness of this transition by proceeding toexplore the psychotic region in a stilted fashion, asking questions in a rigidsequence. To the patient, this exchange could hardly have been reassuring.Let’s see a different interviewer working with the same patient.

PAST PSYCH.

H X.PSYCHOSIS

Fig. 6.

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Exercise #3Patient: It’s been a long haul. Besides all those short hospitalizations, I also

wound up in the State Hospital in 2006.

Clinician: How long were you there?Patient: Oh, about 3 months.Clinician: Any other times you’ve been in a hospital specifically for your

depressions?Patient: No, that about does it. When I was at the State Hospital, I seemed to get

a little better; I’m not really certain why.*Clinician: Do you think any of the medications they used might have helped?Patient: I think that one might have. . . I think, I think it’s called Paxil.Clinician: Do you remember how much you were taking?Patient: I think it was about 20 mg in the morning.Clinician: How do you think it helped?Patient: I didn’t feel as overburdened. I really felt brighter, more energized,

more alive [pause]. I just felt better.Clinician: Have you ever tried any other antidepressants?Patient: A slew of them,Clinician: Do you remember some of their names?


Answer to exercise #3 Past psychiatric history followed by a natural gate moving into the contentregion of the medication history (Fig. 7).

Discussion In contrast to the trainee in the previous exercise, this trainee is moving with

the patient nicely. The patient had mentioned that he had gotten better (noticethat he did not say anything about medications or treatment, as would have

been the case with a spontaneous gate). The trainee cued directly off this laststatement by the patient, building a naturalistic bridge into the content regionof medication history. Nothing fancy here; just a smooth transition created bythe effective use of a natural gate.

PAST PSYCH

HX.MED. HX.

Fig. 7.




Exercise #4Patient: I just don’t feel like doing anything since I’ve been feeling depressed.Clinician: Tell me more about what that feels like.

Patient: Really pretty miserable. Life doesn’t seem the same. I’m tired all the time;no sleep.

Clinician: How do you mean?Patient: Over the past several months sleep has almost become a chore. I’m al-

ways having trouble getting to sleep, and then I wake up all night. It’smiserable.

*Clinician: Have you ever used anything like a nightcap to sort of knock your-self out?

Patient: Yea, sometimes a good belt really relaxes you.Clinician: How much do you need to drink to make yourself feel sleepy?Patient: Oh, not too terribly much. Maybe a couple of beers. Sometimes maybe

more than a couple of beers.Clinician: Just, in general, how many cans do you drink in a given day?Patient: Probably . . . Now, I’m just guessing here, but probably a six-pack or

two. I hold liquor pretty well. I don’t get drunk or nothing.Clinician: What’s your favorite size can of beer, 12 ounces, 16 ounces, 24

ounces?Patient: Usually the bigger ones, they’re a better deal for your money, Doc [pa-

tient smiles].

Clinician: What other kinds of drugs do you like to take to relax.Patient: Well, I might smoke a joint of two here or there [smiles again].


Answer to exercise #4 Depression content region followed by a natural gate moving into the drug andalcohol history (Fig. 8).

DEP. D & A

Fig. 8.

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Discussion We enter this interview when the dyad had been discussing the patient’s de-pressive symptoms for a while (depression had been the patient’s chief com-plaint). In this excerpt the trainee had finished the depression region. Whenthe patient started to complain of severe sleep difficulties, the interviewersmoothly slipped into the drug and alcohol region. By bridging directly off of the client’s last statement, ‘‘I’m always having trouble getting to sleep, andthen I wake up all night. It’s miserable,’’ the trainee used a natural gate tomove the conversation into a new topic. Notice that with a natural gate it isthe interviewer, not the patient, who introduces a new topic. This particularuse of a natural gate was both smooth and clever, because it allowed the inter-viewer to enter a somewhat sensitive topic (eg, drinking habits) unobtrusively.

This trainee displays some very good interviewing skills. Note how she as-tutely asked the patient for the size of beer can—there’s quite a difference be-tween a six-pack composed of 12-ounce cans and one composed of 24-ouncecans. No wonder the patient was smiling! Without this question, this important

bit of information probably would never have surfaced.

Exercise #5Patient: Even though my sister was much older, she still had an impact on me.Clinician: In what kind of way?

Patient: She was always an extrovert, and I’m pretty quiet. Consequently, she wasalways popular, and I was . . . well . . . just not with the ‘‘in crowd,’’ if you knowwhat I mean. Good grades, class president—you name it, she was it.

Clinician: What kind of impact did this have on you?Patient: Not good . . . I sort of hung out . . . That’s all I really did. I was afraid to

be compared, so I kept out of the limelight.Clinician: If you had to do it again, how would you handle those years?Patient: I’d like to think I’d tell her to ‘‘shove off,’’ in my mind. I’d like to think I’d

be more aggressive in doing what I like doing. I’m not my sister. I’m me. ButI’m not so sure I would; I’d guess that’s one of the reasons I’m here . . .

*Clinician: Earlier you had mentioned that you were afraid that drugs wereholding you back. What did you mean?

Patient: Since dropping out of school, I’ve picked up some bad habits. One of them is popping a couple of tabs of speed every day.

Clinician: Do you use anything to bring yourself down?Patient: Sure, sure. ’Ludes and Valium, if I can get a hold of them.Clinician: How long have you been using speed?

Directions

Draw the first and second region connected by the appropriate gate below.




Answer to exercise #5 Psychodynamic process region followed by a referred gate moving into thecontent region of the drug and alcohol history (Fig. 9).

Discussion In the first section, the interviewer was probing in a ‘‘psychodynamic’’ sense,asking questions that require a significant amount of reflection and self-obser-vation on the patient’s part. Indeed, the patient shows a fairly facile ability tolook at herself with some degree of insight, a good sign for the potential to referher to psychotherapy. Because we see only a segment of this interview, it is pos-sible that this dynamic process region, indicated by a circle, may have been

going on for quite some time. It may have originally evolved out of specificcontent regions, such as the social history or the family history. In any case,at this point our interviewer has decided to move on.

Instead of using a potentially disengaging phantom gate, the trainee wiselyopts to enter the new region by referring back to an earlier statement made

by the patient; hence the gate is correctly identified as a referred gate. Noticethat the patient quickly picked up on this referred gate and animatedly joinedin a naturalistic expansion of the content region related to the elicitation of a drug and alcohol history.

Exercise #6Patient: Then my damn aunt came . . . What a turkey! . . . She’s always coming

over. She’s got this disease and that disease. One day she’s got cancer andthe next day she’s sure I have it. Then she’s telling me about what I shouldeat. Honestly . . . it drives me nuts.

Clinician: Sounds frustrating.Patient: Frustrating! You better believe it. She’s God’s gift to busybodies.Clinician: Is she like anybody else in your family?

Patient: A little bit. My mother doesn’t always mind her own business. . .

but Ilive with her. She supports me, so I don’t think I should complain.*Clinician: Do you have any medical problems?Patient: No, not exactly.Clinician: What do you mean?Patient: Well, I’ve had my tonsils out.Clinician: When was that?

DYNAM. D & A

Fig. 9.

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Patient: Back in 1960.Clinician: Any other hospitalizations?Patient: No.

Clinician: Have you had to see your doctor about your heart or lungs?


Answer to exercise #6 Content region of the social history followed by a phantom gate moving intothe content region of the medical history (Fig. 10)

Discussion Needless to say, the transition by this trainee was not the smoothest one onrecord. The client had been discussing various aspects of family relations,

when—out of nowhere—the trainee switched topics. The reason for the subse-quent questions, and their apparent urgency, was certainly unclear to the client,especially because she had been discussing a bit of her social history that wasemotionally important to her. Let’s see an alternative approach.

Exercise #7 Patient: Then my damn aunt came . . . What a turkey! . . . She’s always coming

over. She’s got this disease and that disease. One day she’s got cancer and

the next day she’s sure I have it. Then she’s telling me about what I shouldeat. Honestly . . . it drive s me nuts.Clinician: Sounds frustrating.Patient: Frustrating! You better believe it. She’s God’s gift to busybodies.Clinician: Is she like anybody else in your family?Patient: A little bit. My mother doesn’t always mind her own business . . . but I

live with her. She supports me, so I don’t think I should complain.

SOC. HX.MEDICAL

HX.

Fig. 10.




*Clinician: You know, you had mentioned that your aunt almost drives you nutsworrying about your health as well. Have there been any things in yourhealth that might have prompted any of her fears?

Patient: No, not really. I have had some problems, but all minor league. Al-though even minor league problems can get her going.

Clinician: What kinds of problems have you had?Patient: Well, I had my tonsils out, when I was 6.Clinician: How did that go?Patient: Oh, no problem; just a good way to get some ice cream.Clinician: Any other hospitalizations?Patient: I had my wisdom teeth pulled out; and—oh yea—I was in a car accident

and broke my leg. . ..


Answer to exercise #7 Content region of the social history followed by a referred gate moving into thecontent region of the medical history (Fig. 11).

Discussion What a difference it can make to replace a phantom gate with a more flowing gate such as the referred gate used here. Unlike the trainee in exercise #6, thistrainee wanted to move into the same new region—medical history—but strate-gically used a referred gate that gently moved the conversation into the medicalhistory region. Sometimes referred gates refer back to patient comments made

long ago in the conversation, and sometimes, as in this example, the referredgate points back to a relatively recent patient comment. More distant commentscan be referred to just as easily and seem just as natural and conversational tothe patient, once again metacommunicating that the clinician has been listening carefully. Let’s see yet another direction the interview with the above patientcould have taken.

SOC. HX.MEDICAL

HX.

Fig. 11.

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Exercise #8Patient: Then my damn aunt came . . . What a turkey! . . . She’s always coming

over. She’s got this disease and that disease. One day she’s got cancer and

the next day she’s sure I have it. Then she’s telling me about what I shouldeat. Honestly . . . it drives me nuts.

Clinician: Sounds frustrating.Patient: Frustrating! You better believe it. She’s God’s gift to busybodies.Clinician: Is she like anybody else in your family?Patient: A little bit. My mother doesn’t always mind her own business . . . but I

live with her. She supports me, so I don’t think I should complain.*Clinician: What makes you say that you don’t think you should complain?Patient: It’s sort of complicated, you know, but if I depend on my mother for food

and shelter, well, who the hell am I to complain? But I hate this feeling . . . thisfeeling of being dependent, owing her something. I’m almost 26; I ought tobe on my own.

Clinician: Any ideas about why you haven’t left?Patient: Maybe I’m scared . . . I used to get scared when I was away at college,

you know, homesick. There’s still a lot of little girl in me.Clinician: What role does this little girl play in you?


Answer to exercise #8 Content region of the social history followed by a natural gate moving intoa psychodynamic process region (Fig. 12).

Discussion Notice that the trainee felt she was done with the social history and cued di-rectly off of the patient’s last statement (ie, ‘‘. . . but I live with her. She supports

me, so I don’t think I should complain’’) by using the natural gate, ’’Whatmakes you say you don’t think you should complain?’’ With this skillful useof a natural gate the trainee almost imperceptibly guided the interview intoa psychodynamic region. Note that, as opposed to a free facilitation region,in a psychodynamic region the interviewer peppers the region with interpretivequestions rather than just ‘‘letting the interviewee go.’’

SOC. HX. DYNAM.

Fig. 12.




Naturally there can be some overlap between free facilitation regions andpsychodynamic regions. Sometimes while free facilitation regions are being used, important dynamic considerations pop up spontaneously as the patienttalks freely. But the difference in the two regions can be found by looking atthe primary intent of the interviewer. In a free facilitation region the main in-tent is purely engagement. In a psychodynamic region the main intent is to useinterpretive questions to see how the patient responds, what defense mecha-nisms appear, and the extent of the patient’s own observing ego.

Exercise #9Patient: The situation at work is not good. My boss is short staffed and is pushing

the work on me. And I can’t do it all. He wants to bring in 150 new clients for

the program, simply impossible.Clinician: How does he put the pressure on you exactly?Patient: Basically, by asking me to do his work. That’s what really bothers me. He

might sit in the recreation room shooting pool, while I’m supposed to miss lunch.*Clinician: Earlier you said that you were feeling constantly ‘‘wired’’ at work.

I’m wondering if you ever get the chance to relax?Patient: Occasionally. But even at home I feel pretty uptight.Clinician: How do you mean?Patient: Even when I’m watching TV, I feel restless and worried about work, or

maybe the kids.

Clinician: Do you view yourself as a worrier?Patient: Oh, God, yes! I’m the original worrywart. I spend a lot of time each dayjust pacing around.

Clinician: Do you ever have times when you feel your heart racing?Patient: Oh yea; that’s common, especially if I’m upset. The other day, when I

was mad at Johnny about his grades, I thought my heart would explode.Clinician: Besides things like your heart racing, how often do you get back-

aches, headaches, or other tension-related pains?

Directions

Draw the first and second region connected by the appropriate gate below.

Answer to exercise #9 Content region of the social history followed by a referred gate moving into anexploration of generalized anxiety disorder (Fig. 13).

SOC. HX. G.A.D.

Fig. 13.

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Discussion In this example, two content regions are bridged nicely by a referred gate. Thistime the statement made by the patient, and subsequently referred to by thetrainee, apparently appeared much earlier in the interview and does notshow up in this brief excerpt. This trainee also has increased the effectivenessof the transition by using a referred gate that demonstrates his active concern(ie, ‘‘Earlier you said that you were feeling constantly ‘wired’ at work. I’m won-dering if you ever get the chance to relax?’’) All in all, this transition wasengaging and conversational.

Exercise #10Patient: The depression just seems to get worse and worse.

Clinician: How long has it been going on?Patient Ever since I got back from Christmas vacation. This semester is a lotharder than I was expecting. I’m finding calculus much more difficult thanalgebra.

Clinician: It sounds real tough. Are your symptoms with you all the time?Patient: Yea, I can’t shake them . . .

Clinician: Has it impacted on your sleep?Patient: You bet! Can’t fall asleep, can’t stay asleep, and I wake up early and all

gunked up. Of course, it doesn’t help that my suitemates are big party guys.*Clinician: Are you worrying a lot?

Patient: Almost constantly. I’ve always been a worrier. My Mom used to tell me,‘‘Just go in the corner and worry for 5 minutes and be done with it. Don’twaste the day fretting, it won’t help anything.’’

Clinician: [smiles] Sounds like your Mom had some good advice?Patient: [smiling] Yea, she still does.Clinician: What about relaxing, can you ever relax, you know, say on

a Saturday?Patient: Not really. I’m always wound up tighter than a kite, and I’ve been that

way even before I got depressed.Clinician: When did that begin?

Patient: Probably since around September.Clinician: Hmm . . . so your anxiety has been around for a while. Does it cause

you to have aches and pains, like backaches and headaches?Patient: Oh yea. I get tension headaches all the time. Those started almost as

soon as I started my Freshman year here.





Answer to exercise #10 Content region of major depression followed by an implied gate moving intoan exploration of generalized anxiety disorder (Fig. 14).

Discussion This is the first example of an implied gate in these exercises. The early con-versation focused on an exploration of depressed symptoms, which had beengoing on some time before the excerpt begins. After feeling that she had com-pleted expanding the major depression region, the trainee decided to enter theexpansion of generalized anxiety disorders merely by asking, ‘‘Are you worry-ing a lot?’’ There is significant overlap between depressive symptoms and anx-iety symptoms, so clinicians often use implied gates to move from one to theother with barely a noticeable change in pace. Implied gates can be used anytime two adjacent regions are so congruent in topic that the transition seemsappropriate.

In contrast to a spontaneous gate, in an implied gate the clinician initiates thechange of topic, not the patient. Unlike a natural gate, the implied gate does notcue directly off the preceding one or two statements by the patient. Unlike a re-ferred gate, the interviewer does not refer directly back to a previous statement

by the patient. Finally, in contrast to a phantom gate, the implied gate seems tofit naturally.

When the new region is extremely similar to the preceding region, as in thisexample, an implied gate can be almost imperceptible and rivals a natural gatefor smoothness of transition. If the connected content regions are less similar,an implied gate becomes less smooth and eventually approaches the abruptnessof a phantom gate.

For instance, the clinician could have said, ‘‘Tell me more about yourstressors,’’ instead of, ‘‘Are you worrying a lot?’’ This inquiry would have rep-resented an implied gate into the content region of the patient’s currentstressors, although it would not have flowed quite as well as the previous

example of an implied gate, because the topics are not as similar in nature.In summary, implied gates range in smoothness on a continuum between

natural gates and phantom gates. When the two regions are closely related, im-plied gates approach the gracefulness of natural gates. On the other hand, if thetopics are poorly related, an implied gate can approach the awkwardness of a phantom gate.

G. A. D.DEP.

Fig. 14.

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Discussion The early phase of this excerpt illustrates the expansion of a content regiondealing with obsessive-compulsive disorder. This region is being expanded ina reasonable fashion, when, without any warning, the trainee abruptly asksabout suicide, a clear-cut example of a phantom gate.

This trainee seemed particularly intent on disrupting the conversational flowhere, because he no sooner enters the suicide region than he exits, using yetanother phantom gate into the family history region with the question,‘‘Does anyone in your family have a serious mental illness?’’ Such strings of phantom gates may leave the patient wondering if the clinician knows whathe is doing and certainly can contribute to a ‘‘Meet the Press’’ style interview.In the next example, the interviewer tries a different approach with the samepatient.

Exercise #12Patient: I keep getting the same thoughts over and over. I really don’t understand

it.Clinician: What types of thoughts have been bothering you?Patient: I can’t get it out of my head that I have germs on my hands.Clinician: How do you mean?Patient: I hate shaking people’s hands. If I shake somebody’s hands I will abso-

lutely have to go the bathroom to wash them. I won’t be able to stand beingin the room, until I do.Clinician: How many times might you wash your hands in a day?Patient: At least 100 times. I’m not kidding.Clinician: Are there other actions that you find you have to keep doing over and

over?Patient: This is sort of embarrassing to talk about, but I have a hard time

dressing.Clinician: How do you mean?Patient: Sometimes, when I’m dressing, I have to take my pants off and on 20

times. I count it out. Sometimes it might take me 30 minutes to dress, I getso anxious.*Clinician: That sounds very upsetting and painful. When your worries torment

you like this, do your thoughts ever get so disturbing that you think of killingyourself to escape it all?

Patient: Sometimes I do wonder if it’s all worth it. I mean, why bother, when youreally get down to it? But those thoughts seem to pass quickly.

OCD SUICIDE FAM. HX.

Fig. 15.

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Clinician: When you do get those thoughts of perhaps taking your own life,what exactly do you think of doing?

Patient: One time, about a month ago, when I was really upset, I thought of tak-

ing some pills. . .


Answer to exercise #12Content region of obsessive-compulsive disorder followed by a natural gatemoving into an exploration of suicidal ideation (Fig. 16).

Discussion This exercise is the last one in this Appendix, and it highlights the powerfuldifference the choice of a single gate can make in engagement, conversationalflow, and even in the validity of the patient’s answers. Unlike the previous in-terviewer, this trainee manages to bring up the topic of suicide while simulta-

neously communicating empathy through the skillful use of a natural gatecueing directly off the pain expressed in the patient’s immediately preceding comments. Note the remarkably different history related to recent suicidal ide-ation that results secondary to the difference in engagement between the clini-cian and the patient in the two examples. Technique counts, and facilicsupervision effectively teaches technique combined with compassion.

You have finished the programmed text. We hope it has been of value.Please return to the main body of the article.

References[1] Shea SC, Mezzich JE, Bohon S, et al. A comprehensive and individualized psychiatric inter-

viewing training program. Acad Psychiatry 1989;13(2):61–72.[2] Shea SC, Mezzich JE. Contemporary psychiatric interviewing: new directions for training.

Psychiatry, Interpersonal and Biological Processes 1988;51(4):385–97.[3] Hall ET. The hidden dimension. New York: Doubleday; 1966.[4] Birdwhistell ML. Introduction to kinesics: an annotation system for analysis of bodymotion and

gesture. Louisville (KY): University of Louisville Press; 1952.

OCD SUICIDE

Fig. 16.




[5] Shea SC. Psychiatric interviewing: the art of understanding. Philadelphia: W.B.SaundersCompany; 1988.

[6] Shea SC. Psychiatric interviewing: the art of understanding. 2nd edition. Philadelphia:

W.B.Saunders Company; 1998.[7] Benedek EP. Interpersonal process recall: an innovative technique. J Med Educ 1977;52:939–41.

[8] Training Institute for Suicide Assessment and Clinical Interviewing (TISA), Available at:www.suicideassessment.com.

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